Provider Demographics
NPI:1548642903
Name:ABDI, SAMSAM
Entity type:Individual
Prefix:
First Name:SAMSAM
Middle Name:
Last Name:ABDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 FULLER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4829
Mailing Address - Country:US
Mailing Address - Phone:612-707-8619
Mailing Address - Fax:
Practice Address - Street 1:714 FULLER AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4829
Practice Address - Country:US
Practice Address - Phone:612-707-8619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN464522789171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN464522789OtherTAX ID/EIN